Food insecurity is an ongoing concern in Africa. According to the State of Food Security and Nutrition in the World report by FAO (Food and Agriculture Organization, 2018), the number of undernourished people has increased to nearly 821 million worldwide. Africa remains the continent with the highest prevalence of undernourishment, affecting over 250 million people.
Recent studies show that women with children make up a significant component of the households affected by food insecurity. In our Q&A we highlight this important topic and its connection to maternal mental health.
Read the full Food Security and Nutrition report here
What is food insecurity?
Food security is defined as having enough safe and nutritious food to sustain a healthy life. In contrast, food insecurity means that food is not sufficiently accessible or affordable, so households have difficulty securing adequate food.
What is maternal mental health?
Maternal Mental Health is a term that refers to the emotional state of women during and after pregnancy.
You can read more about perinatal mental health on our website
How is food insecurity linked to maternal mental health?
The relationship between food insecurity and poor maternal mental health is complex, with research showing that there are bi-directional associations between them. That means that suffering from food insecurity can have a negative impact on mental health and having mental health problems can negatively affect food security. The Perinatal Mental Health Project demonstrated these associations in a paper published in 2018.
How does food insecurity affect maternal mental health?
The negative physical health effects of poor maternal nutrition are well documented. Additionally, the emotional strain associated inadequate basic household resources, and how these resources are allocated substantially increases the overall household stress. Food insecurity can have persistent effects on the mental health of household members, especially those responsible for child care.
How can mental health problems during or after pregnancy affect food security?
In low-and-middle-income countries, maternal depression can is associated with an increased prevalence of food insecurity in the household by 50 to 80%. Mental health problems also impact the way food for the household is sourced. Mothers with depression or anxiety may find it more challenging to generate income, make contingency plans and draw on social networks for support. They are more likely to be in relationships characterised by abuse and control.
Breaking the cycle of food insecurity and poor maternal mental health!
Even though the link between the two highlighted issues is being explored worldwide, there is little evidence for interventions that successfully break this cycle.
Currently, many interventions target one or the other issue. While food banks and support grants are aimed at improving the nutrition of mothers and consequently alleviates household food insecurity – they do not address the mental health implications of food insecurity on households. Similarly, maternal mental health services do not typically poverty relief or similar interventions, which could reduce the negative impact food insecurity has on households.
Combined interventions need to be developed and tested for their dual impact on both the mother’s mental health and the food security of the household.
Photo by Annie Spratt, Unsplash
- Effects of maternal depression on family food insecurity by Noonan, K., Corman, H., & Reichman, N. E. (https://doi.org/10.1016/j.ehb.2016.04.004)
- Factors associated with household food insecurity and depression in pregnant South African women from a low socio-economic setting: a cross-sectional study by Abrahams, Z., Lund, C., Field, S., & Honikman, S. (https://doi.org/10.1007/s00127-018-1497-y)
- Food insecurity among adults residing in disadvantaged urban areas: potential health and dietary consequences by Ramsey, R., Giskes, K., Turrell, G., & Gallegos, D. (https://doi.org/10.1017/S1368980011001996)
- Food Insecurity and the Risks of Depression and Anxiety in Mothers and Behavior Problems in their Preschool-Aged Children by Whitaker, R. C., Phillips, S. M., Orzol, S.M. (https://doi.org/1542/peds.2006-0239)
- Food Insecurity/Food Insufficiency: An Empirical Examination of Alternative Measures of Food Problems in Impoverished U.S. Households by Scott, R. I.
- Food Insecurity and Mental Health among Females in High-Income Countries by Maynard, M., Andrade, L., Packull-McCormick, S., Perlman, C., Leos-Toro, C., & Kirkpatrick, S. (https://doi.org/10.3390/ijerph15071424)
The Relationships Between Domestic Violence and Perinatal Depression and Anxiety – A Global Perspective
According to the World Health Organisation (WHO), depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease. Since women are twice as likely to experience depression in their lifetime than men, it is worthwhile to explore the many risk factors that make them more susceptible.
Although depression and anxiety can have devastating effects for any individual – women have an increased chance of being affected by these common mental disorders during the perinatal period, which can have long term consequences for both mother and child.
Domestic violence (DV) and intimate partner violence (IPV) are strongly linked to depression and anxiety in the perinatal period.
Zooming in on Domestic Violence as a risk factor
Domestic violence (DV) is defined as any physical, sexual, psychological or economic abuse that takes place between people who are sharing or have recently shared a home. Intimate partner violence (IPV) relates to violence committed by a current, ex- or would-be intimate relationship that causes physical, psychological or sexual harm to either partner.
The WHO has acknowledged that all forms of interpersonal violence leads to negative health outcomes and released a global plan of action to address interpersonal violence, particularly against women, girls and children. (More in this WHO report 2016)
In Africa, there is more violence against women than on any other continent. Compared to America, twice as many women In South Africa are killed by their partners.
Violence against women during pregnancy can have negative effects for both the mother and the child. Studies have shown that negative physical effects for mother and child can include fetal death by placental rupture, premature labour, low birth weight and haemorrhage after birth.
The negative psychological effects can include lowered self-esteem, depression, anxiety, substance or alcohol misuse. These effects, in turn, render women more vulnerable to experiencing domestic violence. Furthermore, abused women are more likely to delay getting pregnancy care and to attend fewer antenatal visits.
Research on IPV from four countries
Main findings from four countries show that there is a relationship between domestic and intimate partner violence.
A recent study from Australia found that out of the 4% of pregnant women who reported a history of IPV during a routine psychosocial assessment, more than 50% were immigrants. The highest number of women reporting abuse were born in Sudan and New Zealand, while women from China and India were least likely to report IPV. It is important to note that under-reporting is very likely in many communities and this may be due to a variety of reasons such as women’s experiences of shame, stigma and lack of appropriate responses or support from others.
Those women reporting IPV were more likely to report additional psychosocial concerns including depression, thoughts of self-harm and childhood abuse.
Another study conducted in Japan showed the association between verbal and physical abuse during pregnancy and linked it to postpartum depression. The study not only offers some insights into the significant influence of both verbal and physical abuse during pregnancy on postpartum depression, but also calls for regular screening for antenatal IPV by public health nurses who could identify those women who need further support, such as referral to centres for confidential advice and support.
Similar findings were reported from Malaysia, where the exposure to IPV was significantly associated with postnatal depression. The researchers of this study are also calling for training to healthcare professional to detect and manage both problems.
A recent South African study, conducted by the Perinatal Mental Health Project, showed 15% of nearly 400 pregnant women experienced IPV. We found a substantial proportion of women were additionally experiencing violence in the home at the hands of family members other than their partners, such as brothers, in-laws and grandparents. We found that abused pregnant women are more likely to be under 30 years of age, experience a range of mental health disorders, food insecurity and are more likely to be unemployed. They are more likely to have experienced abuse in the past and be unhappy with being pregnant.
‘The atmosphere was tense in the house’ a South African mother’s story.
Further research is needed to establish the best way to identify women at risk of domestic violence or intimate partner violence. A recent systematic review showed that there is promising evidence to indicate that mental health interventions for mothers may reduce their experiences of IPV. However, further research is required to determine the mechanisms and intensity of these interventions.
- Training and supervision
Trauma-informed care, empathy training, referral-making skills and safety planning should be embedded as an integral part of the training and supervision systems for all frontline workers who engage with mothers, across different sectors.
Clinical and policy guidelines provided by the World Health Organisation are available here.
- Systems strengthening
Political will, with the attendant resource allocation, is required to develop the structures able to protect and support survivors. These structures in health (physical and mental), justice, and the non-governmental sectors should operate in a co-ordinated and mutually enhancing way.
The World Health Organisation has produced an excellent manual for health managers for systems strengthening to respond to women subjected to IPV and sexual violence. This includes building awareness, advocating, analysing and planning as well as addressing leadership and governance factors.
Our first newsletter of the year reflects on 2018 and takes a sneak peek into projects and research still to come.
What a year it’s been!
Find out what we’ve achieved and view the highlights of our activities in 2018 in our Annual Report
In most societies, mothers are the primary providers of care to young children. This is a demanding task and the mental health of a mother is not only essential to her well-being, but that of her child’s physical health, nutrition and psychological well-being. However, most child development programmes do not adequately address maternal mental health.
Recent research has shown that about 20% of mothers in developing countries experience some form of mental health problems during or after childbirth. The United Nation’s Secretary-General António Guterres has recently acknowledged that the issue of mental health remains a largely neglected issue and announced the UN’s commitment to “working with partners to promote full mental health and well-being for all”.
Moreover, professionals in the field are pointing out that the mental health of mothers is critical to the success of the UN Sustainable Development Goals on health, nutrition and gender equality (SDG 3, 2 and 5).
In South Africa, the rate of pregnant and postnatal mothers suffering from common mental disorders (depression and/or anxiety) can reach up to one in three. Many of them are poor, come from disadvantaged communities and face many obstacles in accessing services and care.
Across Africa, the majority of women experiencing challenges to their mental health during the perinatal period (pregnancy and up to one year after the birth) are also exposed to gender-based violence, economic and gender inequalities, physical illnesses (including HIV), complications of childbirth and the stresses of childcare. Suicide has been identified as one of the leading causes of maternal death worldwide.
Unfortunately, health care systems in most African countries are not equipped to deal with the complex health and social challenges faced by most mothers. With competing physical health priorities and constrained resources, mental health care remains seriously neglected.
To challenge the status-quo and to improve the mental health of mothers in Africa, a group of individuals and organisations are working together in the newly established African Alliance for Maternal Mental Health (AAMMH).
AAMMH believes that a multi-sectoral approach is needed to tackle the causes of poor maternal mental health in Africa. The alliance calls for the integration of existing evidence-based interventions for the detection, prevention and treatment of maternal mental health problems into reproductive and child health programmes, supported by mental health services with specialist expertise.
This call for action is very close to the PMHP’s mission to develop and advocate for accessible maternal mental health care that can be delivered effectively in low-resource settings. We have thus become involved with the Global Alliance for Maternal Mental Health (GAMMH) over the past year since its formation and are now a proud founding partner of its first regional off-shoot, the AAMMH.
Together with colleagues in Malawi, we have been preparing for the upcoming launch on the 19 June in Lilongwe, Malawi. Prior to the launch, we will conduct a training workshop with health care providers and managers in maternal, mental and child health. On the launch day itself, we will be delivering a keynote address sharing the experience of the PMHP and will also be conducting a workshop towards establishing strategies for working partnerships across sectors for maternal mental health.
We hope our experience and work in South Africa, and in other low and middle-income countries, will contribute to the development and growth of this pan-African advocacy initiative. At the same time, we look forward to collaborating and learning from advocates, practitioners, trainers and researchers across Africa to strengthen the work we do in South Africa.
AAMMH will be officially launched in Lilongwe, Malawi on 19 June 2018. You can follow the event by using the hashtag #AAMMH #GAMMH
Read more about aims and objectives of the AAMMH here.
Source: Maternal Health Task Force blog
Diagnosis gap in Low- and Middle-Income Countries (LMICs)
Despite contributing significantly to maternal deaths and unproductive life years, common perinatal mental disorders (CPMD) often go undetected among women in low-resource regions. This can mean that up to 80% of women remain untreated in such settings. Resource-constrained primary care centers, high patient volumes, lack of recognition by health workers as well as increased task shifting to semi-skilled health workers contribute to this treatment gap. In order to encourage timely identification of CPMD among mothers followed by referrals, antenatal care provision centers are a promising platform in LMICs due to the high level of touchpoints between expectant women and health systems. In South Africa, for example, a mother’s contact rate with any antenatal care facilities is quite high at approximately 91%. […]
Lead author Thandi van Heyningen shares insight into progress and next steps for improving maternal mental health in low-resource settings:
“Where health system resources are scarce, one way of improving detection and improving access to treatment, is to integrate these services into existing, routine, primary health care services using a stepped care approach. Improving detection through routine antenatal screening may provide a vital first step, however there is a need to generate further evidence on the feasibility and acceptability of existing screening tools for use in such settings, and by non-specialist health care workers.”
Perinatal depression and anxiety are serious mental health problems and are among the leading causes of maternal morbidity and mortality worldwide!
Pregnant women are at higher risk for suicidal ideation and behaviours compared to the general population.
Suicide has been identified as one of the major contributors to the global mortality burden and there is a growing concern over the increase in suicidal ideation and behaviour among pregnant women.
Studies in low- and middle-income countries put the rate of maternal death due to suicide at somewhere between 0.65% and 3.55%. In such cases, risk factors include poverty, lack of support, lack of trust in health systems and coexisting mental illnesses.
Suicidal thoughts experienced during pregnancy can continue beyond the initial postpartum period, affecting the well-being of both mother and child.
More about pregnancy and suicidal ideation in our infographic
The negative cycle of mental ill-health and poverty is particularly relevant for women and their infants during the perinatal period. During this time, major life transitions render women more vulnerable to mental illness from social, economic and gender-based perspectives.
Those with the most need for mental health support, have the least access. Overburdened maternal and mental health services have not been able to address adequately this significant unmet need. There have been limited attempts at a programmatic level, to integrate mental health care within maternal care services.
The perinatal period, where women are accessing health services for their obstetric care, presents a unique opportunity to intervene in the event of mental distress. Preventive work involving screening and counselling may have far-reaching impact for women, their offspring and future generations.
Mental health care is a notoriously neglected area – even more so in “healthy” pregnant and postnatal women. The focus on the physical to the detriment of the emotional is particularly felt now against the backdrop of HIV and AIDS. The public health service has been unable to address the mental health needs of women from poorer communities – neither within maternity services nor within mental health services. This is despite a wide body of evidence showing that distress in the mother may have long-lasting physical, cognitive and emotional effects on her children.
The PMHP aims to integrate mental health service routinely, within the primary maternal care environment.
Based at selected government MoU facilities in Cape Town, we offer counselling and support services focused on the emotional wellbeing of pregnant women with a strong focus on postnatal and clinical depression.
Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes.
Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development.
Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences.
This research will provide much-needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low-resource settings that have a high prevalence of IPV and HIV.
Source: BMC Health Services ResearchBMC series
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